If you say its coronary angiogram and the final snapshot of TIMI flow , you need to read further.If you thought its actually the quantum of ECG ST regression . . . great , you can exit this page with credits.

CAG may notbe the gold standard in defining PCI success , it just tells you whether IRA is patent or not .Instead , the good old ECG tells you about whether the myocardium is successfully reperfused or not . TIMI flows are simply not good enough to identify adequacy of myocardial reperfusion .

By the way , who is telling this ?

It appears there is only a narrow gap between Ignorance and Knowledge !

While success of thrombolysis is faith fully subjected to the acid tests of myocardial perfusion , primary PCI is rarely ever assessed in terms of ST segment regression.

What is the next logical step this study should lead us to ?

I think I am not provocating , . . How to get rid of the prevailing practice of jacking up the success rate of primary PCI ? ( Conveniently, Ignoring the echo detected significant LV dysfunction on follow up ) Mind you, this has resulted in creating a new crop of patient sub group called “Angiographic success and myocardial failure”

Reference.

Dear colleagues , please go thorough this article . Its from the thought leaders , Duke University ,North Carolina. I would argue the cardiology fellows to discuss this paper in detail in their journal club as “classic paper” till they completely understand the conclusion .Though its done with GUSTO 1 data in primarily lytic population, its conclusions are very much valid as an assessment tool in reperfusion by any means.I am afraid, even 16 years after this paper got published ,the truth has not penetrated to the targeted population within the cardiology community.

Many probably witness the much talked differential behavior among the gender every day. Its argued , men take more risk in life ( often senseless !) , some go to the extreme to suggest Men are Idiots and decorate them with a provocative title MIT (Men Idiot Theory ) (Mcpherson 2011).Risk taking is important in life, but at what cost ? Does women (Who are caring by nature ) help themselves and the society by less risk taking behavior ?

I stumbled upon this rare piece of writing from BMJ which would demand in depth analysis into this gender phenomenon based on evolutionary biology and genetics.

This article concludes, Yes, men . . . indeed tend to take some foolish risks in various life situations that result in potential harm.

What is the influence of MIT on medical profession and patient outcome ?

Now , Iam compelled to ask a hypothetical question .Does women medical professionals take less aggressive stance and low risk taking behavior and in the process result in less mortality and morbidity to our patients ?

I would think the answer to that question would be in affirmative .I wish BMJ or anyone should design a study on this issue.

News : In any developed nation , 90 % of total health expenditure is exhausted in prolonging final few days of human life !

When cost of dying . . . exceeds cost of living . . . this world will go nuts !

The current real world experience from India’s five star hospitals indicate, many elderly rich men and women spend their last few days before being buried or burnt .They spent an average of 15 lakh Rs per death. This amounts to the entire “life time” cost of living of majority of Indians .

Image courtesy from Flicker/ Rachel sian photostream

When human organ donation is considered a greatest philanthropic act, there is one more excellent alternative for those who can’t do it .If only every super rich translate their cost of dying into cost of others living ! many new lives will bloom .

The exorbitant rise in cost of dying in India , is a recent development and reflects the affluence , honor , prideand of course lots of prejudice lack of wisdom ! Instead of filling the deep pockets of greedy corporates why not the rich add new lives ? !

Final message

Let all elders with irreversible conditions , who have finished their life , shall die peacefully at home .Why don’t we ( Affluent . . . would be cadavers !) cross sponsor their dying cost to a public health , nutrition or medical fund .

After thought

Oh America , . . . Am I right ,? Obama thought it and implementing it too ! I would believe , his health care policy is a small first step in this direction !

I wish to be in New Zealand , not only because of the stunning natural beauty but also to pay tribute to one of the great cardiac surgeons of our time from Auckland .

An alluring country side cricket ground abutting the runway . . . Queenstown I think !

Sir Brian Gerald Barratt-Boyes (1924-2006), Who pioneered all forms of heart surgery that specifically included complex congenial heart disease . Thousands of Kiwi children are alive and leading a magnificent life today because of this man from Green lane an alumni of Mayo .

Many heart surgeons from India and Asia pacific have trained under him .

Green lane Hospital Auckland.

This is the hospital where Barrat Boyes worked headed the department of cardiac surgery .He had to over come large bureaucratic hurdles before becoming world ‘s leading cardiac surgery center. And , he lives everyday in all cardiac units through this book .

In the early 1980s , when cardiac physicians were confronting how to tackle intra coronary thrombus , one man from Japan was looking directly at the ground zero with fiber-optic coronary angioscope .He provided live images of coronary plaques and thrombus (long before the IVUS and OCT era) because of technical difficulties it did not get into clinical utility but gave us vital information like plaque morphology and behavior.

The concept of red and white thrombus

The yellow lipid enriched vulnerable plaques

Post lytic clot surface

The fibrin strands within the clot etc.

The angioscopes have now given way to IVUS and OCT which provide indirect vision of the coronary arteries .Uchida has written a book tilted coronary angioscaopy which is a must read for all clinical cardiologists.

I think Japanese are leading in this aspect of cardiac Imaging .Yasunori Ueda is another person who has done lot of work on angioscopy . here is an Image from his paper. Exciting stuff is isn’t !

Dr Shirely Smith from charring cross hospital London wrote this masterpiece in BMJ in the year 1962 . He was doing a research about the origin of angina like pain in patients who had upper GI disease or disorders of cervical spine .He found a hidden invisible neural link between heart and it’s neighboring viscera. What he referred it as linked angina . It links the pain from ,Esophagus, gall bladder , duodenum , cervical spine to the heart .

This article I consider as one of the all time classics in clinical cardiology . Here is the link for linked angina (Courtesy of BMJ)

High lights ( Inferred ) from the article

We know angina typically occurs on exertion .If it occurs at rest we call it as unstable angina .

Can it occur at rest other than unstable angina ?

Yes it can . ( Post prandial ,Nocturnal, emotional etc)

Can the heart be the referral site for visceral pain ?

Yes .It seems so .

Can visceral pain be trigger for developing true angina ?

Again possible . A Patient with documented CAD develop a true esophageal pain it is likely to induce a sensation of angina rather than abdominal pain .Similarly , cervical pain may represent a masked angina in a patient with active cervical spondylitis .(Homing in of angina to the nearest non cardiac culprit )

Final message

Those were the times when the brain worked more than hands . Common sense prevailed over machine sense .This article argues for a big debate about the origin of so called atypical angina in a patient with multiple common visceral conditions.Even 50 years later we have little clue about alimentary -cardiac neural spill over !

Today we live in a complex and confusing and commercial medical world .We have atleast a dozen chest pain triaging protocols in ER . Still errors are rampant. Errors are acceptable . . . but this one was an absolute shocker . . . “I know a patient with vague chest/epigastric pain , non specific T inversion , documented gall stones , landed in cath lab not by accident but by meticulous planning !”